models of failure such as generic failure types), and thereby supports the assimilation of preventative measures.
The base factual data, concerning the time history, activities, and actions immediately prior to the incident, is extracted from the reported source. In general, the authors have found this data to be in sufficient detail and completeness, professionally recorded and trustworthy. Atypical high level analysis for the grounding
of Royal Majesty (Ref 7) is shown in Annex C to illustrate the methodology used by the authors. Further analysis of this incident has been presented previously (Ref 8).
Where the report highlights something as being a cause, this is identified on the mind map in red. Contributory factors are identified in blue. Where there are questions outstanding from the reading of the report, these are identified. There are a number of instances where correct mitigation or preventative action had been taken. These are identified with a tick.
The approach taken to the incident analysis has the following characteristics:
• it assumes multiple causes • it takes an event-tree approach, where successive 'barriers' to an incident have been breached, but does not make assumptions about the number of breaches required to bring about an incident or the temporal sequence of their construction or breaching
• Although Johnson (Ref 9) warns of the dangers of classification errors, it was decided to attempt a standard structure for attributing causes. It is believed that attributing causes to enabling systems through the life cycle is likely to be less obviously misleading than the types of coding scheme described by Johnson
• It is aimed at identifying potential preventative measures rather than in-depth analysis of causes. Although words such as 'shortfall' and 'error' are used, there is no attempt to assign blame. The interest is in understanding, but principally in corrective action at a systemic level.
Identification of mitigation measures A key outcome of incident analysis is to support industry learning by identifying factors which would have mitigated the risks. To be effective, the mitigation measures must address the most elemental causal factors and not be targeted at some intermediate level. This means that the analysis has to get right back to those basic initiators. This increases the analysis and reporting burden and potentially requires expertise in all parts of the maritime community. However, the alternative is to miss vital opportunities. Further analysis can identify, at the basic level, causal factors which can be dealt with, often without incurring a massive cost penalty or increasing complexity.
Moving to 'learning from incidents' increases the number of lessons that can be learned from an incident. By structuring material around the stakeholders, it is intended that the transfer into good practice can be encouraged.
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It is important that mitigation measures do not make the system more brittle (see Annex B). It is, furthermore, important that mitigation measures have general validity as there is no purpose in simply closing a unique stable door or introducing a measure which might prove counterproductive when applied more widely to different situations. Learning opportunities from incidents must be applied wisely to ensure that the marine industry is well-served.
Experience from application of the structured systems approach Two case studies are detailed in Annex C and Annex D. In each case the basic factual information is taken directly, and only, from the official investigation report.
These
working illustrations need to be read in association with the referenced report to gain a full understanding of the incident.
Conclusion
The need for incident analysis has been formally recognised, and its format codified. The next step, perhaps, is to improve the value of lessons extracted and their adoption by members of the maritime community. Work by Lloyd's Register has indicated that a systems approach to reconstruction and analysis, combined with a simple compact presentation format, offers the potential to glean more information from an incident and to simplify the transfer to corrective or
Locus of shortfall
Design and build time errors Regulatory shortfalls Operational shortfalls
Near-term risk mitigation missed Immediate build-up risks
Post-incident opportunities missed
improvement action. The number of marine incidents that are thoroughly investigated is relatively small and it is important to use these 'tales of what actually happens' to maximum effect.
Since each is, essentially, a sample taken at random, these represent an opportunity to dig beyond the immediate causes of the incident under investigation. The process described here provides an effective way to achieve the desired aim.
Annex A
Systems in the maritime community The system elements/relevant systems have been identified in a number of ways, for example, Rasmussen (Ref 10) has government, regulators, company, management, staff, work. This and the Moray analysis (Ref 11) are based on approaches to analysing each system. The Lloyd's Register basis for identifying relevant systems was by 'systems of work' that affect the safety of operation. They are as shown in the accompanying Table 1.
The relevant systems have been variously portrayed as a hierarchy (Ref 10), a nested hierarchy (Ref 11), and as layered defences in depth (Ref 12). These representations present some conceptual difficulties and are graphically difficult to use for portraying the trajectory of an incident. They are perhaps more appropriate to sectors that are less
Table 1. Details of a typical base used by Lloyd’s Register for identifying systems that affect safety. Relevant system(s)
Design office, shipyard, equipment manufacturer.
Regulators eg, IMO, class, flag, port state control Company Crew
Watch Crew, Rescue service THE NAVALARCHITECT FEBRUARY 2006
Annex C. Illustration of the presentation format: High-level analysis of the incident involving the grounding of the passenger ship Royal Majesty (Ref 7).
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